A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Evaluate the firmness of the uterus (fundus).

Obtain a type and crossmatch.

Administer oxytocin infusion.

Initiate oxygen therapy by nonrebreather mask.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

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Correct Answer is D

Explanation

The correct answer is choice D. At the level of the umbilicus.

Choice A rationale:

The uterine fundus is not typically found to the right of the umbilicus after delivery.

Choice B rationale:

The uterine fundus is not typically found 2 cm above the umbilicus after delivery.

Choice C rationale:

The uterine fundus is not typically found one fingerbreadth above the symphysis pubis after delivery.

Choice D rationale:

After delivery, the uterine fundus is typically found at the level of the umbilicus.

A. Nausea with vomiting during the first trimester. B. Sudden leakage of fluid during the second trimester. C. Urinary frequency in the third trimester. D. Backache during the second trimester. E. Lower abdominal pain with shoulder pain in the first trimester. F. Headache with visual changes in the third trimester.

Correct Answer is ["A","E","F"]

Explanation

The correct answers are choices B, E, and F.

Choice A rationale:

Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.

Choice B rationale:

Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.

Choice C rationale:

Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.

Choice D rationale:

Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.

Choice E rationale:

Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.

Choice F rationale:

Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.

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A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a vaginal delivery 8 hours ago.When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?.

Correct Answer is D

Explanation

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider.Which signs and symptoms would the nurse include? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

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A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.